Low sales and competition.

Medicine shops reported encountering fluctuations in sales, with seasonal variations being a key element of sales patterns. The use of medications varies seasonally, with demand for antimalarials peaking in the rainy season, while for other ailments peaking during the harmattan or dry season. For example, a respondent noted that sales of particular medications “depend on season. This season [December] getting to harmattan, [so there is] a lot of cold medication prescription, with headache, cold, nausea, runny nose. In rainy season there is a lot of malaria because mosquitoes multiply.” The most prevalent challenge mentioned at the level of the shops was in fact low sales volume. Specifically, 13.64% of challenges fell under this category in herbal and chemical shops among all challenges, while comparatively, pharmacies did not mention this concern. We note that unlike wage-based employees, a third of respondents in herbal and chemical shops are shop owners who presumably directly benefit from the proceeds generated by the shop.

The global COVID-19 pandemic was also implicated in the reduced customer traffic and sales. Fearing both a potentially infectious environment and the social and economic repercussions of a positive COVID diagnosis, many would-be customers avoided sites they associated with sickness. Shops’ proximity and patients’ differing access to hospitals and clinics were reported to influence customer traffic and behaviors. A respondent in a pharmacy replied “Sales are low. Malaria symptoms are just like COVID symptoms. If [they] have malaria, just similar to COVID—cough, sneeze, feverish, just the symptoms of COVID. It’s difficult because of this COVID. It interrupted a lot of pharmacies because [would-be customers are] afraid to come for drugs” (35–44 year old female chemical shop owner in a medium-income neighborhood). The shelf life of medicines was related to low sales as a function of the supply chain. Specifically, medicines arrived at or close to their expiry date, and with low sales traffic would expire before they could be sold, e.g., as one said: “expiry of drugs; when drugs arrive they are almost expired and don’t move fast” (35–44 year old male pharmacist in a low-income neighborhood).

Competition, especially among pharmacies, was also relevant to the discussion of low sales. Many shops were observed to cluster around hospitals, and customers often looked for the best price, which may have been available at nearby shops. Customers’ purchasing decisions also appeared to be made based on price above any other factor. Customers typically started at the pharmacy closest to the hospital, inquired about prices, and moved down the line to adjacent medicine sellers until they found the lowest price.

Workplace.

Among the workplace-related challenges cited by respondents were insufficient income, and boredom. These fell under the broader umbrellas of job satisfaction and issues of limited resources mentioned in the existing literature. For instance, one respondent expressed “it gets so boring doing the same thing over and over again” (25–34 year old male pharmacist in a high-income neighborhood). Based on prior work, experiences within a shop are expected to influence the quality of care provided [43], however, as noted above a relative minority expressed such concerns as the most important challenges they face. Individual challenges, such as insufficient income, may, therefore, play into enthusiasm for a job and the capacity of staff to provide high-quality care. The effect may transcend customers, as pay may also affect the likelihood of attrition, a concern highlighted earlier.

The lack of feedback mechanisms, especially as they relate to the provision of factual information, also presents a challenge to shopkeepers. Keeping informed is an undertaking beyond the conventional job description. Without systematic patient education and monitoring, effective antimicrobial stewardship relies on practices beyond the typical duties of respondents, which many have limited experience with. In such contexts, the scope of service of medicine sellers has been observed to depend on individual motivation and perceptions of legitimacy [16]. Thus, the job satisfaction and motivation of these distributors, and their ability to make ends meet from the pay they receive at the individual level, may be considered particularly salient.

Customers’ attitudes.

Customer attitudes were the most prevalent challenge mentioned by pharmacies, and were also prominent in herbal and chemical shops. The role of customers was often described in specific terms, or indirectly, by focusing on the need for a great deal of patience. A difficulty in addressing this challenge is the notion of “the customer is always right” and how this idea influences responses to customer attitudes. Customers’ attitudes, however, should not be considered in isolation. The heightened emotions associated with illness were reported to exacerbate challenges, as articulated by one: “People walk in with anger. When sick, people become frustrated. They ask for a certain drug… Some may insult or say mean things… I try to advise, but they don’t want to be told what he/she should consume” (35–44 year old female MCA in a pharmacy in a middle-income neighborhood). Although the attribution of attitudes occurs in this fashion in our data, it is important to note that this challenge is only mentioned 35% of the time in isolation. In the remaining 65% of cases when it is mentioned, respondents reference challenges with payment in an overwhelming majority of cases, where customers are short on money, can’t afford the medications prescribed or recommended to them, or attempt to buy on credit that is not extended to them. For example, as one respondent connected these issues, they said: “insults… They normally complain of prices, aside that, nothing else [I find challenging]” (18–24 year old female medical counter assistant in a medium-income neighborhood). Multiple respondents also reported customers’ resistance to their inquiries into symptoms or dismissing their advice and linked this to customers’ attitudes. Regarding their stewardship of antibiotics, one pharmacist reported “Some patients don’t understand antibiotics for instance. [Customers say] ‘I am buying, [I] don’t understand why you don’t want to sell it to me.’ Sometimes it turns into an argument” (25–34 year old male pharmacist in a low-income neighborhood).

Self-diagnosis and self-medication.

The practice of self-diagnosis was reported to be widespread. Customers subverted the process of going to hospitals or clinics and instead identified an illness themselves based on the symptoms they perceived relevant. Efforts to self-medicate with over-the-counter medications often brought customers to medicine sellers. This was framed as a challenge when respondents disagreed with patients’ self-diagnoses. Self-medication was mentioned explicitly as a challenge by 10 respondents (12.31% of reasons in pharmacies), notably concentrated in pharmacies, rather than chemical shops or herbal shops. When customers did not have prescriptions, but believed they needed medications such as antibiotics, respondents reported difficulties: “customers tell ‘I want this’ but this medicine will not solve their problem. Sometimes they will not understand why, but I say no [to their request] if I know it won’t help them” (35–44 year old female MCA in a pharmacy in a middle-income neighborhood). Respondents sometimes alluded to their conditional allowance of customer self-medication, perhaps offering medications without prescription if they deemed the chosen treatment course to be useful to the customer.

Adherence.

Completing a full course of antimicrobials is essential for effective treatment and preventing resistance. Respondents reported general uncertainty about customers’ completion of treatment courses and a lack of clarity on the state of antimicrobial resistance in Ghana. To overcome this lack of centralized guidance, one pharmacist reported independently reading scientific articles to remain informed about current best practices, and others said they were doing research on the Internet. Respondents explained that AMR was not one of their main considerations before distributing drugs, but some seemed to be concerned about the rapid emergence of drug resistance that renders their products obsolete.

In a separate question, 41% of respondents reported that they believed that patients “probably” or “definitely” adhered to their entire antimicrobial treatment courses, with one attributing this trust to the fact that “it is expensive, no one wants to waste money” (25–34 year old female MCA in a pharmacy in a medium-income neighborhood). 54.8% answered “might or might not,” and the remaining respondents expected that customers would not complete their treatment courses. Adherence monitoring was described as being carried out at the individual level. When asked “Do you think customers actually finish the entire treatment course of antibiotics after they leave the shop?” one responded “Definitely yes, because I talk to them. I tell them when you don’t finish up with the course, your treatment will not wash off [the infection]” (35–44 year old female chemical shop owner in a medium-income neighborhood). Another reported that they took phone numbers and routinely called patients to verbally ensure that they finished their antibiotic course. The majority had doubts, echoing the respondent who said “Not everybody takes everything. Even though you tell them to finish the course, you realize sometimes somebody does not take the whole course, has 2 days left” (25–34 year old male pharmacist in a high-income neighborhood).

The issue of adherence is closely related to self-medication, and was mentioned by respondents both in herbal and chemical shops, as well as in pharmacies. This issue was highlighted in herbal or chemical shops relatively more frequently (6.82%) compared to pharmacies (1.54%). Some respondents mentioned the potential for drug abuse; one believed that it occurs “especially [for] antibiotic and analgesic” medications (25–34 year old male pharmacist in a middle-income neighborhood), and another explained that they responded to such situations by dodging the customer’s request: “If I think they will abuse it, I tell them it is out of stock” (35–44 year old female MCA in a pharmacy in a middle-income neighborhood). Although it was unclear what was explicitly interpreted as “abuse,” the context of antimicrobials suggests that abuse could involve either taking an excessive dosage at once, not taking all prescribed medication, or using medicines for effects other than their prescribed purpose.

The inconsistent availability of dosage strengths and treatment options was described as a challenge for some respondents. Medications that required frequent dosages (such as every four hours, or tablets with small dosages that required taking up to four pills at each interval) were reportedly disliked by customers. Some customers would decline to purchase these medications, and respondents expressed concern that patients who did purchase these typically lower-cost medicines likely would not adhere to their regimens.

Role incongruence in treating customers.

The role of medicine dispensary employees in the diagnosis and treatment of disease was also considered. Treatment-related issues came up as challenges in a variety of ways, and were mentioned more prominently in herbal or chemical shops compared with pharmacies. These mentions included role-conflict, where customers perceived respondents as physicians. Some respondents noted that they lacked the necessary training to respond to their customers’ needs. This was especially salient when facing complicated symptoms or navigating situations without diagnostic testing to establish the appropriate course of treatment. These instances and an absence of information often impeded respondents’ ability to tailor their advice and dispense medicines. A respondent reported that “People consider you as a doctor, see you as a doctor. It becomes very challenging if you make a mistake because you’d be held responsible” (45–54 year old female pharmacist in a high-income area).

The disparity between licensed roles and actual practice thus came up as a challenge. Respondents suggested that formal medical institutions were not able to meet the health needs of the general public. As a result, they found themselves asked to fill roles beyond simple medicine distribution. For instance, customers without prescriptions sometimes sought diagnosis within medicine dispensaries. Although some could be easily treated, such as malaria with rapid diagnostic testing, others were less straightforward. Facing complicated symptoms was mentioned as a challenge in this context: “facing difficult cases of illnesses that I cannot help with,” (45–54 year old female chemical shop owner in a low-income neighborhood) that underscores gaps between distributors’ individual knowledge and the demands of a fragmented healthcare ecosystem.

Payment.

As described by staff at dispensaries, paying for medications was more than a mild concern for customers. The cost of medications was an obstacle for the majority of their clients. Although cost was always a large barrier for customers, prices varied widely by shop. Individual medications were priced according to the brand and origin of the medication production. The cost of antimalarial medications was typically lower for generic and locally produced, relative to imported, brands. In general, prices for medicines varied from shop to shop. One respondent mentioned that a “patient might return with the same condition just because they couldn’t afford a drug” (25–34 year old male pharmacist in a low-income neighborhood) and another reported “after you finish giving out the medicine, he/she will be like ‘the money is too much, I can’t afford, your things are too expensive,’ and the person will just go out without buying. This mostly happens, happens often” (45–54 year old female MCA in a medium-income neighborhood).

Financial stress was reported to affect the relationships cultivated between respondents and their customers, and manifested in different ways, such as attempting to buy on credit. Other respondents reported yet different strategies, such as “customers trying to return sold drugs” (55–64 year old female chemical shop owner in a middle-income neighborhood). Most shops explicitly specified that they required payment immediately at the time of sale. Some individual shopkeepers occasionally trusted customers with credit allowances to pay later, which was more common for repeat customers. One reported that for patients who were “struggling and can’t pay, I give and pay the rest out of my own funding” (18–24 year old female MCA in a chemical shop in a medium-income neighborhood).

Education.

Many shopkeepers sought to influence the health-seeking behaviors of their customers, often by advising and informing them of medicines that would be most useful given their condition. In some cases, these workers viewed their role as countering the (mis)information circulating among the general public. In other cases, they mentioned that the illiteracy or lack of education of the typical customer created a challenge when interacting about the proper course of treatment. They noted, in their view, that illiteracy and a lack of knowledge at the community level were almost insurmountable to fix. This lack of education may have been a driver of other challenges, such as self-diagnosis. One respondent explained that “people coming in with self-diagnoses and the medications they want, sometimes without considering your recommendations or opinions” created their biggest challenge, thus “trying to get them to understand why they don’t need an antibiotic for a very trivial issue” (18–24 year old pharmacist in a middle-income neighborhood). Education was pointed out by pharmacists in particular as one in ten challenges faced. Coincidentally, this challenge was not mentioned by respondents in chemical shops or herbal shops. Given the differences in background and training of medicine distributors by shop type, it is possible that pharmacists and trained MCAs perceived this challenge more acutely, and suggests that this challenge may also be present in herbal or chemical shops, albeit not at the forefront of concerns for shopkeepers there.

Language barriers.

Some respondents reported a language barrier, specifically when working in neighborhoods with large communities known for being hubs of in-migration. This was framed as a challenge for understanding and responding to medical conditions. Specifically, language barriers represented 9.09% of all challenges in herbal or chemical shops, and 6.15% of all challenges reported in pharmacies. These challenges may have been more manageable for long-serving respondents (who were far and few) who had established rapport in their communities. This underscores again the importance of community interactions in shaping the gravity of challenges perceived by respondents, and should be considered in light of the relatively high turnover reported earlier.

Diagnostic access.

Some stores reported that they did not offer diagnostic testing for malaria because tests could be accessed at a hospital nearby. However, such an assumption may mean that customers who cannot afford hospitals do not have access to on-demand diagnostic tests in lower-cost medicine shops. Shops located closer to hospitals faced less difficulty with customers, as their patients were more likely to have undergone diagnostic testing and bring prescriptions. Conversely, shops farther from hospitals struggled with a lack of access to diagnostic resources. One respondent reported as their primary challenge the insufficient “availability and accessibility of diagnostic tests and diagnostic facilities for customers or patients” (25–34 year old pharmacist in a middle-income neighborhood). The lack of diagnostic testing may have manifested in other challenges, such as self-diagnosis and self-medication, discussed in the Customer category.

Brands.

The role of “brand” was considered important in decisions around the efficacy of medicines. Some respondents voiced a stronger belief in the efficacy of imported or originator brands than local generic brands, with one saying “you can never compare generics to innovator, [imported originator brands being] more efficacious” (25–34 year old male MCA in pharmacy in a middle-income neighborhood). Many customers shared these views, and reportedly established preferences for particular medications based on prior experiences, advertisements, or reports from acquaintances about which medications effectively cured their ailments. Two respondents specifically reported as their biggest challenges the television and billboard advertising that they believed shaped customers’ preferences in this way. One explained that their biggest challenge was “trying to convince a patient to buy another type of drug aside from what he or she thinks is good or what a layperson or TV/radio advert [advertisement] has explained” (18–24 year old male healthcare assistant in a chemical shop in a high-income neighborhood). These respondents perceived a responsibility to work against advertisements (and other laypeople), believing that their expertise was better informed than market forces such as advertising.

Supply chains.

Part of the reason for lacking certain medications is related to supply chain issues. Herbal or chemical shops sold a variety of artemisinin-based combination therapy (ACT) antimalarials, and pharmacies tended to sell a variety of both imported and local brands of antibiotics. Respondents described varying degrees of confidence in each brand, but could not always procure the preferred variety, as articulated by the respondent who said “sometimes the medicine they want, we don’t have it” (25–34 year old male employee of a pharmacy in a high-income neighborhood). As an example, when one respondent explained their biggest challenge they said “In my shop, for instance, I think probably the lead time of the medications. And actually, sometimes the drugs you request that you want, they don’t really come. They [the wholesaler] will just give you what they have in their warehouse” and cited the challenge of “owing suppliers due to low sales and expiry of drugs” as a corollary (25–34 year old female pharmacist in a medium-income neighborhood). We note that some shops did not experience delay between running out of a medication and resupplying, and a further 30 reported that medicines could be restocked within a matter of days.

Challenges of a global nature expected but not mentioned.

Prior studies suggested that the lack of public health policy or lack of enforcement posed a challenge. Earlier studies have reported that in the present context, policy enforcement is sporadic and health regulation infringement is frequent [31, 50]. Indeed, respondents reported little faith in regulations to improve their practices and identified challenges with potential policy implications, i.e., low diagnostic capacity, increasing prices, difficulties with supply management, and uncertain drug quality assurance. No respondent referenced national or municipal regulation as a strategy to alleviate their challenges, as laws or inspections would more likely be seen as impediments to business. In contrast, respondents expressed general disillusionment with policy-making and the absence of expectation of government support or action on the concerns they face.